Monkeypox: Challenging Clinical Questions
Authors: Christine Laine, Darilyn V. Moyer, Deborah Cotton
Journal: Annals of Internal Medicine (2022)

Special Articles14 October 2022Monkeypox: Challenging Clinical QuestionsFREEChristine Laine, MD, MPH, Darilyn V. Moyer, MD, and Deborah Cotton, MD, MPHChristine Laine, MD, MPHEditor in Chief, Annals of Internal Medicine (C.L.), Darilyn V. Moyer, MDExecutive Vice President and Chief Executive Officer, American College of Physicians (D.V.M.), and Deborah Cotton, MD, MPHDeputy Editor, Annals of Internal Medicine (D.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-3040 Eligible for CME Point-of-CareCME/MOC SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In May 2022, monkeypox emerged in nonendemic regions of a world weary from years of dealing with COVID-19. The first U.S. case was reported on 17 May 2022, and on 4 August 2022 the Centers for Disease Control and Prevention (CDC) declared monkeypox a public health emergency. As of 30 September 2022, CDC was tracking 71 408 cases in more than 100 countries (1). Thankfully, as we approach mid-October 2022, the monkeypox outbreak seems to be ebbing. Among the 12 countries with the highest cumulative cases reported, the United States, Canada, and European countries are experiencing clear declines in incidence.However, the virus remains a concern. As of 11 October 2022, there were 26 778 cases and 2 monkeypox-related deaths in the United States (1, 2). Monkeypox will likely continue to occur in previously nonendemic areas, although not at the dramatic rate initially feared. Consequently, clinicians need information about the prevention and management of an infection most have never encountered before. On 11 October 2022, Annals of Internal Medicine and the American College of Physicians gathered a panel of experts to provide that information in a virtual forum.The panelists, all specialists in infectious diseases, were Dr. Roy M. Gulick (Rochelle Belfer Professor in Medicine, Weill Medical College of Cornell University), Dr. Cassandra M. Pierre (Assistant Professor of Medicine, Boston University Chobanian & Avedisian School of Medicine), and Dr. Stuart N. Isaacs (Associate Professor of Medicine, University of Pennsylvania Perelman School of Medicine). Dr. Deborah Cotton (Deputy Editor of Annals of Internal Medicine and Emerita Professor of Medicine, Boston University Chobanian & Avedisian School of Medicine) moderated the program. The program began with presentation of 3 clinical vignettes. After polling the participants about what they would do in each scenario, the panelists shared their own approaches. The panelists then addressed specific questions submitted by attendees.The discussion covered a wide range of issues, such as the care of a patient at high risk for monkeypox infection but without a definite exposure; appropriate use of the only vaccine approved to prevent monkeypox; risk for transmission via various routes of exposure, including from contact with fomites; interventions to prevent spread in health care settings; and appropriate use of tecovirimat and other antiviral agents. The panelists largely agreed on the approaches to the clinical vignettes presented, but they repeatedly emphasized that we lack clinical trial evidence to define optimal use of vaccination and treatment.While we continue to learn about modes of transmission, Dr. Pierre emphasized that it is largely via direct skin-to-skin contact or prolonged and close face-to-face contact. Although the virus can persist on surfaces and porous materials like bed linens, this does not to date seem to convey high risk. The CDC recommends that personal protective equipment in health care settings include masks, eye protection, gowns, and gloves. However, transmission in health care settings has not been observed during this outbreak, even among health care personnel with varied adherence to protective equipment (3).Preventive strategies include avoiding high-risk behaviors and vaccinating individuals at risk for infection. The JYNNEOS vaccine is the only vaccine with U.S. Food and Drug Administration approval to prevent monkeypox infection. While the eligibility criteria for the vaccine were narrow early in the pandemic, the CDC has liberalized the criteria so that eligibility encompasses people who were exposed or are concerned they may have been exposed or may be exposed in the future. While single-dose regimens and intradermal dosing have been used or considered as strategies to stretch vaccine supply, the CDC recommends the approved 2-dose, subcutaneous regimen. A very important point made by the panelists is that persons previously vaccinated for smallpox should not assume that their prior vaccination protects them from monkeypox. If at risk for monkeypox, they should receive the JYNNEOS vaccine.The panelists noted that tecovirimat was approved for the treatment of smallpox, not monkeypox, as part of bioterrorism preparedness and that approval was based on data in animals, not humans. Currently, tecovirimat is indicated for use in patients who are immunocompromised or who have severe disease characterized by widespread lesions, severe pain, and/or systemic symptoms. Tecovirimat's benefit is uncertain when prescribed for immunocompetent patients with milder illness. To provide needed evidence, Dr. Gulick encouraged clinicians to consider enrolling eligible patients in the STOMP trial (Study of Tecovirimat for Human Monkeypox Virus), a randomized trial of tecovirimat versus placebo in immunocompetent patients with mild disease (4). Administering tecovirimat to people with milder symptoms may increase the chance that the monkeypox virus develops resistance to the medication.When contrasting recent experiences with COVID-19 and monkeypox, the panelists emphasized that we had a vaccine and an antiviral agent in our toolbox from the beginning of the monkeypox outbreak, whereas the COVID-19 toolbox was empty when COVID-19 emerged. However, making sure that the public health infrastructure is strong and stable is essential to effective and equitable use of available tools to save lives, reduce illness, and keep emerging diseases from becoming pandemics. Well-informed clinicians are also essential, so we encourage you to watch the video of this program.Video. ACP/Annals Monkeypox Forum: Challenging Clinical Questions The ACP/Annals Monkeypox Forum, held on 11 October 2022, features speakers Deborah Cotton, MD, MPH; Roy M. Gulick, MD, MPH; Stuart N. Isaacs, MD; and Cassandra M. Pierre, MD, MSc. (Duration 1:23:52)References1. Centers for Disease Control and Prevention. Monkeypox: 2022 Outbreak Cases and Data. Updated 30 September 2022. Accessed at www.cdc.gov/poxvirus/monkeypox/response/2022/index.html on 11 October 2022. Google Scholar2. Centers for Disease Control and Prevention. Monkeypox: 2022 U.S. Map & Case Count. Updated 11 October 2022. Accessed at www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html on 11 October 2022. Google Scholar3. Marshall KE, Barton M, Nichols J, et al; Colorado Healthcare Personnel Monitoring Team. Health care personnel exposures to subsequently laboratory-confirmed monkeypox patients - Colorado, 2022. MMWR Morb Mortal Wkly Rep. 2022;71:1216-1219. [PMID: 36136939] doi:10.15585/mmwr.mm7138e2 CrossrefMedlineGoogle Scholar4. Study of Tecovirimat for Human Monkeypox Virus (STOMP) [clinical trial]. Accessed at https://clinicaltrials.gov/ct2/show/NCT05534984 on 11 October 2022. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Editor in Chief, Annals of Internal Medicine (C.L.)Executive Vice President and Chief Executive Officer, American College of Physicians (D.V.M.)Deputy Editor, Annals of Internal Medicine (D.C.)Disclosures: All relevant financial relationships have been mitigated. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-3040.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he is employed at Johns Hopkins University. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.Corresponding Author: Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]org.This article was published at Annals.org on 14 October 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics LatestKeywordsAntiviralsCOVID-19Health careMonkeypoxPrevention, policy, and public healthRandomized trialsResearch laboratoriesSafety equipmentSystemic diseasesVaccines ePublished: 14 October 2022 CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...